Public Awareness About Sexually Transmitted Diseases in Taif, Saudi Arabia

Introduction: Islamic culture does not tolerate homosexuality and extramarital sex. This may result in ignorance of safe sex practices and a lack of proper public health education by the authorities and parents; this includes knowledge and awareness about sexually transmitted diseases (STDs), modes of transmission, protection methods, and sources of information about STDs. Methods: This is a cross-sectional study, a Quick Response (QR)-code-based survey. A standard web-based questionnaire was electronically delivered to our enlisted sample. The statistical analysis started by transferring data from the Excel spreadsheet (Microsoft Corporation, Redmond, Washington, United States) to the SPSS software program. We used one-way ANOVA to compare mean scores between the various groups. And we used the Pearson correlation coefficient to assess the association of age with the score. Significance was established at a p-value of 0.05 or less with a 95% confidence interval. All statistical calculations were performed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States). Results: The study analysed the sociodemographic characteristics and STD knowledge of 608 participants. Findings revealed a balanced gender distribution, 52.8% male and 47.2% female, the majority being single (72.0%) and with a university education (72.0%). Knowledge gaps were identified, such as confusion between genital herpes and HIV, limited understanding of chlamydia transmission, and misconceptions about human papillomavirus (HPV) and HIV. No significant differences were found based on sex, age, marital status, or father’s education. However, higher education of mother correlated with significantly higher knowledge scores (p < 0.0001). Conclusion: This study shed light on the limited knowledge and misconceptions surrounding STDs in Taif city. The findings highlighted knowledge gaps, including confusion between different STDs and misconceptions about transmission modes. The results revealed a positive correlation between higher maternal education and increased knowledge scores. These findings underscore the urgency for health authorities to develop awareness campaigns and educational initiatives to promote accurate information and foster healthier attitudes toward sexual activity in these regions.


Introduction
Sexually transmitted diseases (STDs) refer to a variety of clinical syndromes and infections caused by pathogens that can be acquired and spread through sexual activity [1]. Today, STDs comprise diseases caused by viruses, bacteria, fungi, protozoa, helminths, and arthropods [2]. The key problem with these illnesses is that patients may show no symptoms and go undiagnosed [3]. However, certain sexually transmitted infections (STIs) can harm women's reproductive systems permanently if left untreated, and they can be transmitted from mother to child during pregnancy and childbirth. The World Health Organization estimates that more than a million STDs are acquired every day [4].
There is a lack of information regarding both STD epidemiology and the awareness level of prevention in Islamic nations where homosexuality and extramarital sex are forbidden [5]. A study that used a different questionnaire in Saudi Arabia in 2016 showed that participants are unaware of the types, modes of transmission, and methods of STD protection [6].
This study uses a previously validated questionnaire, called the STD knowledge questionnaire, and aims to explore knowledge and awareness about STDs among Taif city residents, including modes of transmission, protection methods, and sources of information. More importantly, the study encourages health authorities to establish more awareness campaigns and educational programs about STDs.

Tools and data collection procedure
The questionnaire used was distributed via multiple data collectors; the data collectors filled the questionnaire electronically, and they were instructed on whom to reach out to and how to properly fill the questions, without influencing their responses. A previously validated web-based questionnaire was delivered to our randomly selected sample by data collectors. The questionnaire we used was the Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ) [7] with 27 questions and with six more demographic questions at the beginning to ensure eligibility and to analyze the data. The first section focuses on social and demographic information, including gender, age, educational level of the respondent, educational level of both parents, and marital status. The second section evaluates the knowledge of STDs. The questionnaire was translated into Arabic and validated in 2018 [3].

Statistical analysis
Simple descriptive statistics of the sociodemographic characteristics and other categorical variables in the form of frequencies and percentages were calculated and tabulated. For continuous variables, means and standard deviations were reported as measures of central tendency and dispersion, respectively.
To find the association of the total score with the sociodemographic characteristics, one-way ANOVA was applied and interpreted as the statistical method of choice for comparison of mean scores between the various groups. To assess the association of age with score, the Pearson correlation coefficient was calculated. Significance was established at a p-value of 0.05 or less with 95% confidence interval. All statistical calculations were performed using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States).

Sociodemographic characteristics
The data provided in Table 1 represents the counts, percentages, mean, and standard deviation for various sociodemographic characteristics including sex, age, marital status, subject's education, father's education, and mother's education. Out of the total 608 participants, 287 (47.2%) were female, while 321 (52.8%) were male. The ages of the participants ranged from 18 years to 41 years with a mean age of 25.8 years and a standard deviation of 6.1 years. Regarding marital status, the majority of participants (72.0%) were single. A significant proportion of participants were married (24.0%), while smaller percentages were divorced (2.6%) or widowers/widows (1.3%).  The educational levels of the participants' fathers showed a diverse distribution. The highest proportion of fathers had completed a university education (42.3%), followed by those with secondary education (26.2%). A smaller percentage of fathers were illiterate (11.7%), had a primary education (10.5%), or had a middle school education (9.4%). The educational background of fathers mirrored the diverse educational landscape of the participants. Similar to the fathers, the mothers of the participants exhibited a range of educational backgrounds. The highest percentage of mothers had a university education (38.2%). Additionally, 19.7% of mothers were illiterate, while 11.3% had completed primary school, 11.3% completed middle school, and 19.4% completed secondary school.
The sample displayed a relatively equal distribution between males and females. The majority of participants were single, and a significant proportion had pursued a university education. The educational levels of both fathers and mothers varied, with a considerable number attaining a university education. These findings provide valuable insights into the sociodemographic composition of the participant sample and may be relevant for further analyses and interpretation of study results.    The correlation analysis revealed a very weak positive correlation between age and score, with a Pearson correlation coefficient of 0.028. However, this correlation was not statistically significant, as indicated by a p-value of 0.494 (two-tailed test). Thus, the participants' age does not appear to have a substantial impact on their scores.

Comparison of knowledge of STDs
The analysis revealed no statistically significant difference in the mean scores among participants with different marital statuses: single (Mean = 8.6, SD = 5. Thus, the father's education did not appear to have a significant impact on the participants' total scores. There was a statistically significant difference in the mean scores among participants with different levels of mother's education: illiterate (Mean = 8.2, SD = 5.7), primary (Mean = 8.0, SD = 5.2), middle school (Mean = 8.2, SD = 5.0), secondary (Mean = 7.5, SD = 4.9), and university (Mean = 9.9, SD = 5.4), F (4, 603) = 5.170, p < 0.001. The results indicate that higher levels of mothers' education were associated with significantly higher scores.

Discussion
Our study utilized the STD-KQ to assess participants' knowledge and understanding of various STDs and related topics. The findings from the questionnaire responses provide valuable insights into the participants' awareness levels and highlight areas of sufficient knowledge (for example, more than half of the participants acknowledged that it is easier to attract HIV when another STD is already attracted, and that gonorrhoea has a cure), and areas with significant knowledge gaps (for example, the vast majority of participants falsely thought that genital sores soon develop after attracting HIV, and that recurrent urinary tract infection increases the likelihood of attracting chlamydia(.
The study revealed a relatively higher level of knowledge regarding the availability of treatment options for gonorrhoea, with 50.8% of participants correctly recognizing that there is a cure for this infection. The relatively higher knowledge level in this area may be attributed to increased public health efforts to promote awareness about the curability of gonorrhoea.
Furthermore, the finding that a majority of participants (55.8%) correctly recognized that having another STD increases the risk of acquiring HIV demonstrates a satisfactory understanding of the interrelationship between different STDs. This result is consistent with previous studies that have highlighted the association between co-infection with other STDs and increased HIV susceptibility [8,9]. It is encouraging to see this level of awareness, as it underscores the importance of comprehensive sexual health education that addresses the interconnectedness of various STDs.
From the findings of our study, it is also evident that certain misconceptions and knowledge gaps persist among the general population regarding STDs. For instance, only 41.4% of participants correctly identified that genital herpes is not caused by the same virus as HIV. This finding aligns with previous studies that have reported a lack of awareness about the distinct viral causes of these two diseases [10,11]. This knowledge gap underscores the importance of targeted education campaigns to clarify misconceptions and improve understanding regarding the different aetiologies of STDs.
Similarly, the finding that only 17.3% of participants knew that frequent urinary infections cannot cause chlamydia indicates a significant knowledge gap. To address this knowledge gap, educational interventions should focus on providing accurate information about the modes of transmission for chlamydia, emphasizing the importance of safe sexual practices.
Approximately 31.6% of participants mistakenly believed that HPV can cause HIV. This finding aligns with previous studies that have reported confusion or misinformation regarding the relationship between HPV and HIV [12,13]. It is essential to provide accurate information regarding the distinct nature of these infections to dispel misconceptions and ensure that individuals are well-informed about the risks associated with each disease.
Moreover, a relatively low proportion of participants (39.0%) correctly identified that there is no vaccine available for chlamydia. This result indicates a need for further education regarding the available treatment options for chlamydia [14]. While vaccines are available for certain STDs, such as HPV, the absence of a vaccine for chlamydia emphasizes the importance of other preventive measures, including consistent condom use and regular testing.
A significant majority of participants (58.9%) incorrectly believed that having anal sex increases the risk of acquiring hepatitis B. This misconception indicates a lack of awareness about the specific modes of transmission for hepatitis B, which include exposure to infected blood, unprotected sexual contact, and sharing contaminated needles [15]. It is thus essential to educate the public about the transmission routes of hepatitis B, including the risks associated with various sexual practices, to promote safer behaviours and prevent the spread of the disease.
The findings also revealed misconceptions regarding the transmission of STDs. For example, only 41.0% of participants correctly understood that a woman with genital herpes can transmit the infection to her baby during childbirth. This finding aligns with prior studies that have indicated a lack of awareness about the potential risks of perinatal transmission of genital herpes [16]. Comprehensive sexual health education should include information about the modes of transmission for STDs during pregnancy and childbirth to ensure individuals are well-informed about the potential risks and take appropriate preventive measures.
Furthermore, approximately 33.7% of participants incorrectly believed that genital warts can only be acquired through vaginal sex. This misconception highlights a knowledge gap regarding the modes of transmission for genital warts. It is crucial to educate individuals about the various ways in which genital warts can be transmitted, including through oral and anal sex, to ensure a comprehensive understanding of the risks associated with this infection.
STDs are common, but many people do not have enough information about them. This can lead to risky sexual behaviour and the spread of STDs. There are a number of reasons why people may not know much about STDs. Some people may not have received adequate sexual health education, while others may have been taught inaccurate or outdated information. Additionally, some people may be reluctant to talk about STDs because they are seen as taboo or embarrassing.
To address these knowledge gaps, health education programs should focus on providing accurate and up-todate information about STDs. Incorporating evidence-based interventions, such as interactive workshops, educational campaigns, and comprehensive sexual health curricula can effectively improve knowledge and promote healthy behaviours [17]. Additionally, utilizing various channels for information dissemination, such as social media platforms, websites, and healthcare providers, can reach a wider audience and ensure accessibility to accurate information. Also, encouraging parents to participate in the health promotion process by addressing these issues with their offspring more liberally, thus breaking the cycle as early as when these young people start their sexual lives.
Our study also compared the knowledge of STDs among participants based on various sociodemographic characteristics. Firstly, the analysis of sex differences indicated that there was no statistically significant disparity in the mean scores between males and females. This finding aligns with previous studies such as Burrell et al. [18] and Adeyemi [19], which also reported no significant differences in STD knowledge between genders. Therefore, our study supports the notion that gender does not play a significant role in influencing individuals' knowledge of STDs.
Regarding age, the correlation analysis revealed a very weak positive correlation between age and the scores. However, this correlation was not statistically significant, indicating that age does not have a substantial impact on participants' knowledge of STDs. These results are consistent with the study conducted by Smith et al., which found no significant association between age and STD knowledge among their participants [20].
The examination of marital status revealed no significant differences in the mean scores among individuals with different marital statuses. This finding is consistent with the study by El-Tholoth et al., which also reported no significant variations in STD knowledge based on marital status [6]. Thus, marital status does not seem to significantly influence individuals' knowledge of STDs.
In terms of the subject's education level, although the difference in mean scores was marginally insignificant, there appeared to be a potential trend toward higher scores among participants with primary education. This finding is consistent with the study by Mwambete et al., which found that individuals with higher levels of education generally exhibited greater knowledge of STDs [21]. However, further research with a larger sample size is warranted to explore this potential trend in more detail.
Regarding the influence of parents' education, the analysis showed that father's education level did not have a significant impact on the participants' total scores. These findings align with the study conducted by Wanje et al., which also found no significant association between father's education and STD knowledge [22]. However, interestingly, mother's education level was significantly associated with participants' knowledge of STDs. Higher levels of mother's education were associated with significantly higher scores. This finding is consistent with previous research by Koray et al. and supports the notion that maternal education plays a crucial role in shaping individuals' awareness and understanding of STDs [23].

Limitations
It Is important to note that this study has certain limitations. Firstly, the participants' responses were based on self-reported knowledge, which may be subject to recall bias or social desirability bias. Additionally, the study sample may not be representative of the general population, as it consisted of a specific group of individuals who were more reachable by the data collectors. Future research should aim to include a more diverse sample to ensure broader generalizability of the findings.
The age range of the participants was between 18 and 41 years, with a mean age of 25.8 years and a standard deviation of 6.1 years. This is considered a limitation for the study because the older age group is underrepresented in comparison to the younger. In terms of marital status, the majority of participants (72.0%) were single, while a significant proportion (24.0%) were married. A lower percentage of participants were divorced (2.6%) or widowers/widows (1.3%). Thus, if the study was conducted on married people only, a different outcome would be expected. Another limitation is that most participants (72.0%) had pursued a university education, indicating a higher level of educational attainment within the sample. Hence, there is a skew towards higher-educated people.
The educational backgrounds of the participants' fathers and mothers also provide insights into the sociodemographic composition of the sample. The fathers exhibited a diverse distribution of educational levels, with the highest proportion having completed university education (42.3%). Similarly, the educational background of the mothers varied, with the highest percentage having a university education (38.2%). These findings suggest that the participants came from families with diverse educational backgrounds, which may influence their own educational attainment and potentially impact the study outcomes.

Conclusions
This study shed light on the limited knowledge and misconceptions surrounding STDs in Taif city. The findings highlighted knowledge gaps, including confusion between different STDs and misconceptions about transmission modes. The results revealed a positive correlation between higher maternal education and increased knowledge scores. These findings underscore the urgency for health authorities to develop awareness campaigns and educational initiatives to promote accurate information and foster healthier attitudes toward sexual activity in these regions.